The Care Quality Commission: Regulating the quality and safety of health and adult social care

Transcription

1 REPORT BY THE COMPTROLLER AND AUDITOR GENERAL HC 1665 SESSION DECEMBER 2011 Department of Health The Care Quality Commission: Regulating the quality and safety of health and adult social care

2 Our vision is to help the nation spend wisely. We apply the unique perspective of public audit to help Parliament and government drive lasting improvement in public services. The National Audit Office scrutinises public spending on behalf of Parliament. The Comptroller and Auditor General, Amyas Morse, is an Officer of the House of Commons. He is the head of the NAO, which employs some 880 staff. He and the NAO are totally independent of government. He certifies the accounts of all government departments and a wide range of other public sector bodies; and he has statutory authority to report to Parliament on the economy, efficiency and effectiveness with which departments and other bodies have used their resources. Our work led to savings and other efficiency gains worth more than 1 billion in

3 Department of Health The Care Quality Commission: Regulating the quality and safety of health and adult social care Ordered by the House of Commons to be printed on 30 November 2011 Report by the Comptroller and Auditor General HC 1665 Session December 2011 London: The Stationery Office This report has been prepared under Section 6 of the National Audit Act 1983 for presentation to the House of Commons in accordance with Section 9 of the Act. Amyas Morse Comptroller and Auditor General National Audit Office 28 November 2011

4 The Care Quality Commission is the independent regulator of health and adult social care services in England. Its objective is to protect and promote the health, safety and welfare of people who use these services. National Audit Office 2011 The text of this document may be reproduced free of charge in any format or medium providing that it is reproduced accurately and not in a misleading context. The material must be acknowledged as National Audit Office copyright and the document title specified. Where third party material has been identified, permission from the respective copyright holder must be sought. Printed in the UK for the Stationery Office Limited on behalf of the Controller of Her Majesty s Stationery Office /11 STG

5 Contents Key facts 4 Summary 5 Part One The role of the Care Quality Commission 11 Part Two The Care Quality Commission s resources 17 Appendix One The essential standards of quality and safety 38 Appendix Two Methodology 40 Appendix Three Events at Winterbourne View 41 Part Three Registering health and adult social care providers 25 Part Four Ensuring health and adult social care providers comply with the essential standards of quality and safety 31 The National Audit Office study team consisted of: Leon Bardot, Annabel Kiddle, Rachael Lindsay, Vanessa Todman and Dan Ward under the direction of Laura Brackwell. This report can be found on the National Audit Office website at For further information about the National Audit Office please contact: National Audit Office Press Office Buckingham Palace Road Victoria London SW1W 9SP Tel: enquiries@nao.gsi.gov.uk Website:

6 4 Key facts The Care Quality Commission: Regulating the quality and safety of health and adult social care Key facts 139m The Commission s spending in ,600 The number of organisations currently registered by the Commission 14% The percentage of the Commission s staff positions vacant at 30 September per cent the decrease in the recurring budget for regulating health and adult social care between and per cent the decrease in grant-in-aid (for recurring and transitional costs) provided by the Department of Health between and per cent of the Commission s spending covered by fees in ,500 10,500 GP practices to be registered between September 2012 and April per cent of provider registrations not completed on time 47 per cent of planned compliance reviews completed in the second six months of Over 90 per cent of compliance reviews have involved an on-site inspection since April the average number of data items available to inform the Commission s risk assessments of adult social care providers, compared with 500 for NHS trusts

7 The Care Quality Commission: Regulating the quality and safety of health and adult social care Summary 5 Summary 1 The Care Quality Commission (the Commission) is the independent regulator of health and adult social care services in England. Its objective is to protect and promote the health, safety and welfare of people who use these services. The Commission is a non-departmental public body, overseen by the Department of Health (the Department). In , its spending was 139 million, funded by grant-in-aid and fees paid by health and social care providers. 2 The Commission was established under the Health and Social Care Act 2008 and began operating on 1 April It brought together three predecessor organisations the Healthcare Commission, the Commission for Social Care Inspection and the Mental Health Act Commission. In , the Commission ran the three previous regulatory systems while developing its own new system. From April 2010, it began operating using its new powers, set out in the Health and Social Care Act The Commission regulates health and adult social care through its quality and safety assurance work, which comprises: registering providers against 16 essential standards of quality and safety (Appendix One); checking registered providers are complying with the essential standards, including by carrying out inspections; taking enforcement action against providers where services fail to meet the essential standards; and carrying out special reviews of particular aspects of care, and investigations where concerns about quality have been identified. Figure 1 overleaf outlines the Commission s regulatory model. 4 This report examines how the Commission has used its resources in carrying out its quality and safety assurance work. Our methodology is summarised in Appendix Two. 5 The Commission also has a number of other statutory functions including visiting patients whose rights are restricted under mental health legislation and publishing information about the services it regulates to drive choice and improvement. These functions are not covered by this report.

8 6 Summary The Care Quality Commission: Regulating the quality and safety of health and adult social care Figure 1 Regulating health and adult social care Registration The provider sends in an application form The form is checked by the Commission s central team The form is passed to a regional registration assessor The assessor judges whether the provider is compliant with the essential standards The Commission publishes its judgement Monitoring compliance The Commission collects data on the provider Compliance review A compliance inspector judges whether the provider can demonstrate compliance with each essential standard by analysing data and, in most cases, inspecting the provider The Commission publishes its judgement Judged to be compliant Judged to be non-compliant Enforcement Immediate concern of risk of harm/persistent concern Major concern/minor concern not addressed Minor concern The Commission takes enforcement action, e.g. cancels the provider s registration The Commission takes enforcement action, e.g. issues a warning notice, imposes/varies conditions of registration, suspends registration The Commission makes recommendations of the compliance actions the provider must undertake to become compliant Ongoing monitoring Source: National Audit Office

9 The Care Quality Commission: Regulating the quality and safety of health and adult social care Summary 7 6 The role of the Commission in regulating health and adult social care has been the subject of considerable public interest in the past six months because of: a BBC Panorama programme in May 2011, which exposed serious abuse of patients by staff at Winterbourne View, a residential hospital for people with learning disabilities (Appendix Three); the winding-up in July 2011 of Southern Cross, previously the largest care home provider in the UK, with a total of 31,000 residents in 750 homes; the Mid-Staffordshire NHS Foundation Trust public inquiry, which is examining the role of the commissioning, supervisory and regulatory bodies in the monitoring of this Trust; and the Commission s national report on dignity and nutrition in NHS hospitals, and its investigation report on Barking, Havering and Redbridge NHS Trust, both published in October Key findings 7 The regulators for health and adult social care have been subject to considerable change in the last ten years. The Commission is the third regulator for each sector, although it is the first to cover both health and social care providers. The changes have created disruption for providers and confusion for the public. 8 The proposal to extend the Commission s role into new areas risks distracting the Commission from its core work of regulating health and adult social care. The Department proposes that the Commission should take on a variety of additional responsibilities, such as overseeing fertility clinics and responsibility for HealthWatch England, the national consumer body for health and social care. 9 There is a gap between what the public and providers expect of the Commission and what it can achieve as a regulator. Although the Commission s role is clearly defined, it has changed over time and has not always been communicated effectively. The Commission has also not made clear what success in delivering its priorities would look like. The Commission s improved website aims to address this expectation gap by setting out more clearly what the public and providers can expect from the Commission. 10 The Commission s budget is less than the combined budget of its predecessor bodies, although it has more responsibilities. The budget for health and adult social care regulation fell from 175 million in to 164 million in , a reduction of 6 per cent.

10 8 Summary The Care Quality Commission: Regulating the quality and safety of health and adult social care 11 Responsibility for funding the regulation of health and adult social care is falling increasingly on the providers of these services rather than the Department. The Commission is moving towards full cost recovery and the proportion of its spending covered by fees increased from 34 per cent in to 58 per cent in The grant-in-aid given by the Department has fallen considerably by 49 per cent between and , although 11 per cent of the fall is accounted for by the inclusion of funding for transitional costs in The Commission underspent against its budget for and , partly because it had a significant number of staff vacancies. At the end of September 2011, 14 per cent of staff positions were vacant, of which 40 per cent were registration assessor and compliance inspector posts. The Commission has been unable to fill vacancies promptly and was subject to the government-wide recruitment constraints, which meant it needed the Department s approval to recruit new staff. 13 The timetable for registering health and adult social care providers, set by the Department, did not allow time for the registration process to be tested properly and the process has not run smoothly. Although 21,600 organisations are currently registered, the timetable for two out of three tranches of providers was not met. Providers were critical of the registration process and the Commission s initial processing arrangements were inefficient. 14 The Commission is seeking to learn lessons for the registration of GP practices, which has been deferred by a year. The postponement has allowed the Commission time to engage with GPs at an early stage, streamline the application process, and develop online services to make registration quicker and more efficient. 15 Compliance review and inspection work fell significantly during and The Commission completed only 47 per cent of the planned number of reviews between October 2010 and March The reduction in compliance activity was due to the Commission deciding to prioritise registration over compliance, as it diverted resources in a bid to meet the statutory timetable for registration. Levels of compliance activity were also adversely affected by the number of inspector vacancies. Compliance work is now increasing and, in the light of the Winterbourne View case, the Commission is proposing to inspect NHS, independent healthcare and adult social care providers at least once a year from April The Commission has a systematic approach to assessing the risk that providers are not meeting the essential standards of quality and safety, but it depends on good quality information which is not always available. The quality and risk profiles for adult social care contain on average only a tenth of the data items of the profiles for the NHS. Concerns have also been raised that some compliance inspectors do not have the expertise to assess risk effectively and that differences in approach are leading to inconsistency.

11 The Care Quality Commission: Regulating the quality and safety of health and adult social care Summary 9 17 The Commission has strengthened its whistleblowing arrangements in the light of the Winterbourne View case. Whistleblowing concerns are monitored to make sure they are followed up and the information provided is included in regional risk registers. The registers list providers where major concerns have been identified; in November 2011, the Commission had major concerns about 407 providers, 94 per cent of whom were adult social care providers. 18 The Commission s performance management is constrained by gaps in data and reporting is mainly against quantity-based measures of activity. There are a small number of time-related measures but no quality or outcome indicators for regulating health and adult social care. The Commission has established a project to improve its management information. Conclusion on value for money 19 The Commission had a challenging task in merging three former regulators to establish a new organisation and in implementing a new regulatory approach, which integrates health and social care, at a time of diminishing resources. It was inevitable that there would be some transitional difficulties and that it would take time for the Commission to settle down into a steady state. In the event the difficulties were considerable. 20 The ultimate measure of the Commission s value for money is the impact of regulation on the quality and safety of care, relative to the cost. In the absence of measures of impact, we assessed value for money in terms of whether the Commission delivered what it set out to deliver in its quality and safety assurance work. With the exception of NHS trusts, the Commission did not meet the deadlines set for registering providers; at the same time, levels of compliance and inspection activity fell significantly, although the Commission was hampered by government-wide recruitment constraints which made it difficult to fill vacancies quickly. We therefore conclude that, although regulation is being delivered more cheaply, the Commission has not so far achieved value for money in regulating the quality and safety of health and adult social care. It is not clear to us exactly where the balance of responsibility lies between the Commission and the Department for failing to achieve value for money, but it is clear that responsibility is shared. Recommendations 21 The Commission has begun to take steps to improve performance and address some of the issues highlighted in this report. Our recommendations are designed to reinforce these actions and more generally help the Commission deliver better value for money in regulating health and adult social care. a The Commission has not made clear what success in delivering its priorities would look like. Together with the Department, the Commission should define, as far as possible in measurable terms, the outcomes it wants to achieve in regulating health and adult social care, against which progress can be measured. The Commission could also use its networks of representatives of providers and the public in this exercise, which would help bridge the expectation gap.

12 10 Summary The Care Quality Commission: Regulating the quality and safety of health and adult social care b There are shortcomings in the Commission s performance management arrangements. In particular, the Commission needs to: develop performance measures that go beyond the current largely activitybased indicators to cover issues of quality, cost and timeliness; address gaps in performance data, in particular by collecting data on the types of enforcement action taken and the timescales; and report more performance information to the public, including on the impact of enforcement action, which will help the Commission demonstrate its effectiveness and provide reassurance to the public. c d Registering GP practices will be a key test for the Commission next year. Drawing on lessons from previous registrations, the Commission should develop a detailed plan which specifies key milestones and resourcing requirements. The Department and the Commission should review progress regularly so timely decisions, such as whether resources should be diverted from other work, can be taken if GP registration does not go to plan. The Commission s compliance inspectors need better support and information to help them make sound, consistent judgements. The Commission should: identify more data sources for adult social care, for example by using information from other bodies such as the Local Government Ombudsman; enable inspectors to view the risk profile across their whole portfolio; and identify how best to support newly recruited inspectors, who will be working from home and who may lack the experience and support networks of existing inspectors. e f g Whistleblowing should be a key source of information for the Commission to detect poor quality or unsafe care. The Commission should review whether its new whistleblowing arrangements are working effectively, particularly to check that all concerns are being followed up and appropriate action is being taken. There is a risk that extending the Commission s role will distract it from its core work of regulating health and adult social care. Before making decisions, the Department should assess the costs and impact of giving the Commission additional responsibilities and determine whether the Commission has the capacity to take on an extended role. It is uncertain how much money the Commission will need in the longer term to regulate health and adult social care effectively. The Commission and the Department should monitor the resourcing position closely as the Commission gains more knowledge about the quality of care in the various sectors it regulates, and make informed and timely decisions about the resources required, taking account of the level of risk they are prepared to tolerate.

13 The Care Quality Commission: Regulating the quality and safety of health and adult social care Part One 11 Part One The role of the Care Quality Commission 1.1 This part of the report covers the role of the Care Quality Commission (the Commission). Regulating health and adult social care 1.2 There has been considerable change in the regulation of health and adult social care in the last ten years. The Commission is the third regulator for each sector (Figure 2), although it is the first to cover both health and social care. The changes have created disruption and additional work for providers, and confusion for the public. The new system has, however, brought more providers within the scope of the regulator and regulation now focuses more on outcomes than processes. Figure 2 Changes in the regulation of health and adult social care since 2000 April 2000 April 2004 April 2009 Healthcare regulation Commission for Health Improvement Mental Health Act Commission Healthcare Commission National Care Standards Commission Care Quality Commission Adult social care regulation Social Services Inspectorate Commission for Social Care Inspection Source: National Audit Office

14 12 Part One The Care Quality Commission: Regulating the quality and safety of health and adult social care 1.3 The Commission is a non-departmental public body, overseen by the Department of Health (the Department). It was established under the Health and Social Care Act 2008 to protect and promote the health, safety and welfare of people who use health and adult social care services by regulating the provision of such services. It began operating on 1 April 2009, bringing together three bodies the Healthcare Commission, the Commission for Social Care Inspection and the Mental Health Act Commission. 1.4 The Commission regulates services provided by the NHS, private companies and not-for-profit organisations whether in hospitals, GP or dental surgeries, ambulances, care homes or people s own homes. The providers of adult social care and independent healthcare range from major companies, such as Bupa, to small agencies providing home care and individual private doctors. Figure 3 shows the providers that the Commission regulates, which we estimate account for approximately 10 per cent of gross domestic product in England. Currently over 21,000 providers in over 40,000 locations are registered. 1.5 The Commission regulates health and adult social care through its quality and safety assurance work, which comprises: registering health and adult social care providers against 16 essential standards of quality and safety (Appendix One); checking providers are complying with the essential standards; taking enforcement action where services fail to meet the essential standards; and carrying out special reviews of particular aspects of care, and investigations where concerns about quality have been identified. Figure 3 Providers regulated by the Commission Type of provider Number of providers Number of locations 1 NHS trusts 309 2,500 Adult social care providers 2 12,255 25,313 Independent healthcare providers 3 1,169 2,575 Dentists 7,686 9,532 Independent ambulance services Out-of-hours providers from October N/A GP practices 4 from September ,500 10,500 10,000 13,000 NOTES 1 A provider may deliver services in more than one location. 2 Adult social care includes residential homes, day care services and home care services. 3 For example, private hospitals, hospices and private doctors. 4 The exact number of GP practices and locations has yet to be determined. Source: Care Quality Commission

15 The Care Quality Commission: Regulating the quality and safety of health and adult social care Part One Public expectations of the Commission are high. As a regulator, however, the Commission cannot eliminate every incident of poor quality or unsafe care, nor completely mitigate the risk of it occurring. What it can do is deter poor quality or unsafe care and inspect effectively those it regulates to uncover systematic bad practice. 1.7 While the Commission s responsibilities are clearly defined, we found evidence that they have not always been effectively communicated. For example, our stakeholder consultation and the Commission s own provider survey indicated that providers and commissioners of care are unclear about the Commission s role in relation to quality assurance. Additionally, they consider that the Commission s provision of advice and information has been inconsistent. The Commission s improved website sets out more clearly what the public and providers can expect from the Commission. 1.8 Uncertainty about the Commission s role may also arise because the landscape for oversight of health and adult social care is complex, with a number of other bodies having a role to play (Figure 4 overleaf). Providers are responsible for the quality and safety of care, and should have appropriate management and control structures to monitor and take corrective action where necessary. Commissioners should satisfy themselves about the quality and safety of the care they are buying, and the nine statutory regulatory councils for care professionals regulate the conduct of individual staff. The Commission s other responsibilities 1.9 The Commission has other statutory functions including: visiting patients whose rights are restricted under mental health legislation to ensure that their rights are protected; publishing information about the services it regulates to drive choice, change and improvement; and providing an annual state-of-care report to Parliament The Department proposes to extend the Commission s role to include a number of additional responsibilities. The changes risk distracting the Commission from its core work of regulating health and adult social care. It is not yet clear what additional resources the Commission would receive to carry out the additional functions, which include: establishing HealthWatch England, from October 2012, as a statutory committee of the Commission to act as the independent national consumer champion for health and social care; some functions of the Human Fertilisation and Embryology Authority, such as the licensing and monitoring of fertility clinics, and of the Human Tissue Authority, such as regulating organisations that remove, store and use tissue for research and other purposes; the statutory functions of the National Information Governance Board to promote, improve and monitor information governance in health and adult social care; and operating a joint licensing and registration system with Monitor (the regulator of foundation trusts) to make sure that any conditions imposed upon registered providers and licence holders are not inconsistent or contradictory to each other.

16 14 Part One The Care Quality Commission: Regulating the quality and safety of health and adult social care Figure 4 The health and adult social care landscape Department Department of Health Regulators 1 Care Quality Commission Monitor 5 Nine professional regulatory bodies 2 Individuals Patients, carers and the public Providers Adult social care Independent healthcare Independent ambulance services Dentists GPs Out-ofhours care NHS trusts NHS foundation trusts Complaints handling bodies Local Government Ombudsman 1 Parliamentary and Health Service Ombudsman 4 Commissioners Local authority commissioners Department-funded commissioners 3 NOTES 1 Solid arrows show lines of accountability; dotted arrows represent complaints referrals. 2 The nine bodies cover health and adult social care workers, such as dentists, doctors, pharmacists and midwives. 3 Currently primary care trusts commission department-funded healthcare services. By April 2013, these services are expected to be commissioned by the NHS Commissioning Board and clinical commissioning groups. 4 The Ombudsman can handle complaints about independent healthcare and private ambulance services only if the care was funded by the NHS. 5 Monitor determines whether NHS trusts are ready to become foundation trusts and regulates those trusts that achieve this status. Source: National Audit Office

17 The Care Quality Commission: Regulating the quality and safety of health and adult social care Part One When the Commission was established, it had a role in conducting periodic reviews of the commissioning of health and social care by primary care trusts and local authorities. However, it stopped carrying out this work in 2010 when the Department asked it to focus on regulating providers. The Department proposes that in future this responsibility will be undertaken by the NHS Commissioning Board for health and by local authorities themselves for social care The Commission is not responsible for investigating individual complaints about care services, even if it receives them. In the first instance, responsibility for dealing with complaints rests with the provider concerned. If complainants feel they have not received an adequate response from the provider, they may approach the Parliamentary and Health Service Ombudsman for complaints about the NHS, or the Local Government Ombudsman for complaints about adult social care In June 2010, the Commission stopped awarding star ratings based on its assessments of residential social care. The previous regulator, the Commission for Social Care Inspection, had awarded zero to three stars (poor, adequate, good and excellent) to drive improvements in, and inform the public about, the quality of care. The Care Quality Commission, however, judges simply whether or not providers are meeting essential standards of quality and safety, rather than making more graduated assessments While the Commission does not award star ratings, it does provide information to help the public make informed choices about care providers. Its website 1 received more than 5.2 million visitors in In the light of concerns about the quality and accessibility of the information provided, the Commission launched an improved website in October 2011, with separate sections for providers and the public. It is also encouraging the public to provide details of their experience of individual providers. The Commission s governance 1.15 The Department oversees and supports the Commission in a variety of ways, including regular meetings with the Commission s senior staff, regular discussions with the Chair and Chief Executive, quarterly accountability review meetings and daily contact at working level. The Department monitors the Commission s financial and operational performance and risks at a strategic level. It does not assess the Commission s regulation of individual providers The Commission has set two priorities: to focus on quality and act swiftly to eliminate poor quality care; and to make sure care is centred on people s needs and protects their rights. We found that the Commission has not made clear what success in delivering these priorities would look like. The definition of success will depend to some extent on the level of risk that the Commission and the Department are prepared to tolerate in regulating health and adult social care. This risk appetite appears to have changed in the light of the Winterbourne View case. A clear understanding of risk appetite should be central to decisions about resourcing and priorities. 1

18 16 Part One The Care Quality Commission: Regulating the quality and safety of health and adult social care 1.17 The Commission s Board meets every three months and reviews performance using a corporate scorecard of largely quantity-based measures of activity, with a small number of time-related measures. The scorecard has no quality indicators to measure the Commission s quality and safety assurance work, and in some cases the data reported has been incorrect. In addition, the effectiveness of the Commission s performance management and reporting is limited by gaps in the scope of the data available. For example, data are not available on the types of enforcement action carried out and the length of time taken to register providers. The Commission has established a project to improve the quality of its management information.

19 The Care Quality Commission: Regulating the quality and safety of health and adult social care Part Two 17 Part Two The Care Quality Commission s resources 2.1 This part of the report covers the Commission s resources and staffing. How the Commission is funded 2.2 Responsibility for funding the regulation of health and adult social care is falling increasingly on the providers of these services rather than the Department. In , the Commission received grant-in-aid from the Department of 92 million and fees from providers of 80 million (Figure 5 overleaf). For , grant-in-aid is 65 million, a fall of 49 per cent since Removing the funding provided for transitional costs in (see paragraph 2.6) reduces the fall in grant-in-aid to 38 per cent. 2.3 In line with Treasury guidance, 2 the Commission is moving towards full cost recovery for its quality and safety assurance work. The proportion of spending covered by fees increased from 34 per cent in to 58 per cent in No timetable has been set for achieving full cost recovery, however, and the rate of progress depends partly on the political appetite for increasing fees, as the Commission s fee scheme has to be approved by the Secretary of State for Health. 2.4 In April 2010, the Commission implemented a new fee structure, which introduced fees for NHS providers for the first time, bringing them into line with adult social care providers. The fees charged depend on the size and type of provider (Figure 6 on page 19). The fees paid by the NHS are funded by the taxpayer but those paid by other providers are likely to be passed on, at least to some extent, to the recipients of care in the form of increased charges. There is no cap on the fees for residential social care providers as they are charged per location, which their representative bodies regard as unfair. 2 HM Treasury, Managing public money, October 2007.

20 18 Part Two The Care Quality Commission: Regulating the quality and safety of health and adult social care Figure 5 Grant-in-aid and other income for health and adult social care regulation, to million Healthcare Commission Commission for Social Care Inspection Mental Health Act Commission Care Quality Commission Grant-in-aid Other income NOTES 1 Grant-in-aid includes provision for recurring and transitional costs. 2 Other income consists mainly of fees from providers. Source: Annual reports of the four regulatory bodies from to The Commission s budget and spending 2.5 The Commission s budget is less than the combined budget of its predecessor organisations, although it has more responsibilities. Despite this, the Commission underspent in both and , meaning that it did not make full use of the resources available. 2.6 The Commission s budget for its first year of operation was agreed by the Department as part of the work leading up to the Commission being established. The budget consisted of: recurring costs, which represented the cost of performing functions inherited from the three predecessor bodies as well as several new activities; and transitional costs, which represented the costs of setting up the Commission and designing the new regulatory system.

21 The Care Quality Commission: Regulating the quality and safety of health and adult social care Part Two 19 Figure 6 Fees charged by the Commission Provider How fees are calculated Minimum fee ( ) Maximum fee ( ) NHS Annual turnover 40, ,000 Residential social care Each location charged separately based on maximum resident capacity 250 per location 11,100 per location Non-residential social care Number of locations 1,000 32,000 Non-NHS hospital-related healthcare providers Other independent healthcare providers Number of locations 8, ,000 Number of locations 1,500 48,000 Dentists Number of locations ,000 Independent ambulance providers Number of locations ,000 NOTE 1 The Commission has not yet set the fees that GP practices will pay. Source: Care Quality Commission 2.7 The Commission s recurring budget (Figure 7 overleaf) incorporated cost reductions achieved by its predecessors in earlier years, arising from, for example, reducing the number of staff and offices, and changes in working practices, such as introducing home-working for inspectors. In , the recurring budget was million, a 6 per cent reduction on the combined budget of the Commission s predecessors in of 175 million. The Department and the Commission assumed that efficiency savings would be generated by merging the three bodies, including further reductions in the number of staff and offices. The Commission reduced its offices from 23 to 8 in The Commission underspent against its recurring cash budget for and by 3.8 million (2.6 per cent) and 13.1 million (9.0 per cent) respectively (Figure 8 overleaf). The underspend in was largely the result of: an underspend of 9.8 million on staff costs as a result of the number of vacancies during the year (paragraphs ); and an underspend of 2.8 million on external consultancy services owing to the consultancy restrictions applied by the Government from May 2010.

22 20 Part Two The Care Quality Commission: Regulating the quality and safety of health and adult social care Figure 7 Recurring budget for health and adult social care regulation, to million Healthcare Commission Commission for Social Care Inspection Mental Health Act Commission Care Quality Commission Source: National Audit Office analysis of departmental data Figure 8 The Commission s initial budget and spending, to Budget ( m) Spending ( m) Difference ( m) Budget ( m) Spending ( m) Difference ( m) Budget ( m) Transitional spending (8.8) Recurring cash spending (3.8) (13.1) Depreciation and non-cash items (1.2) (3.8) 15.0 Accounting adjustments 0 (1.4) (1.4) 0 (25.3) (25.3) 0 Total spending (15.2) (42.2) Source: National Audit Office analysis of Commission and departmental data

23 The Care Quality Commission: Regulating the quality and safety of health and adult social care Part Two 21 The allocation of resources 2.9 To manage its work effectively, the Commission needs to make informed decisions about the resources it needs and how to allocate them. It is currently moving towards a more evidence-based resourcing model for its regional workforce, with the introduction of activity logs in February 2011, which provide a better picture of how staff spend their time The resourcing model indicates that, if all vacancies were filled, the Commission would have enough inspectors to cover current levels of compliance activity. However, additional work will certainly be involved in regulating out-of-hours providers and GP practices. Furthermore, while the Commission can make assumptions to inform its business planning, it remains uncertain how many resources it will need in the longer term. If the Commission finds more poor quality care, it will need to increase its compliance and enforcement work and may therefore need more resources The Commission has implemented a new integrated approach to resource allocation. For its first year, it allocated its registration and compliance staff to either health or adult social care. For example, inspectors inherited from the Healthcare Commission were assigned to work on NHS trusts. In May 2010, the Commission brought together health and social care regulation with the introduction of mixed portfolios for regionally-based registration assessors and compliance inspectors The Commission s nine regional teams are assisted by intelligence and evidence officers and a shared service centre (Figure 9 overleaf). The service centre was established in October 2010, bringing together the national processing centre, responsible for office administration, and the national contact centre, the main contact point for providers and users. Staff vacancies 2.13 The Commission s operations have been hampered by a significant number of staff vacancies, which it has been unable to fill promptly. The Commission recruited 58 staff between May 2010 and June 2011, but the number of vacancies increased over time (Figure 10 on page 23). At the end of , 6 per cent of staff positions were vacant increasing to 12 per cent by the end of At the end of September 2011, 14 per cent of positions were vacant, equalling 268 staff, including 108 registration assessors and compliance inspectors (40 per cent of the total) In seeking to fill the vacancies, the Commission was affected by the governmentwide recruitment constraints introduced in May 2010, which meant that only frontline or business critical staff could be recruited. In September 2010, the Department decided that the Commission s staff did not fall within its definition of frontline, 3 but that many of the staff, including registration assessors and compliance inspectors, did meet the definition of business critical. 3 Those positions or services that have direct contact with patients and service users in order to provide health or care services, or are critical to the successful operational delivery of such frontline positions or services.

24 22 Part Two The Care Quality Commission: Regulating the quality and safety of health and adult social care Figure 9 Key roles in the Commission s quality and safety assurance work Headquarters (705 posts, 589 filled) Shared service centre (278 permanent posts, 170 filled) Provide a helpline for staff, providers and the public Receive and process compliance evidence and notifications Receive and validate registration applications Regional intelligence and evidence officers (47 posts, 44 filled) Work within a regional intelligence and evidence team Interpret data and deliver analytical advice to inspectors and assessors in their area Look for cross-region trends 9 regional teams Regional director (7 posts, 7 filled) Registration manager (13 posts, 13 filled) Accountable for the quality and consistency of decisionmaking on provider registration Approve all decisions to refuse a provider registration Compliance manager (74 posts, 76 filled) Accountable for the quality and consistency of compliance monitoring Approve compliance reports and enforcement action Accountable for sourcing expert advice in support of compliance monitoring Manage relationships with NHS trusts and large health and social care providers Registration assessor (129 posts, 103 filled) Assess whether applicants are complying with the essential standards Determine whether the Commission has enough evidence to make a judgement and weigh any evidence of concerns Make judgement on whether a provider can register with the Commission Compliance inspector (726 posts, 625 filled) Hold a portfolio of providers Undertake planned and responsive reviews of compliance for their portfolio Manage relationships with providers in their portfolio (except NHS trusts and large health and social care providers) NOTE 1 Number of filled staff posts is at 31 August 2011, when there were 1,979 posts of which 1,627 were filled. Source: National Audit Office

25 The Care Quality Commission: Regulating the quality and safety of health and adult social care Part Two 23 Figure 10 Staff vacancies, to Vacant positions Q1 Q2 Q3 Q Q1 Q2 Q3 Q4 Q1 Q Registration assessor and compliance inspector vacancies Other vacancies NOTE 1 The negative number represents staff inherited from the predecessor bodies that were surplus to requirements. Source: National Audit Office analysis of Commission data 2.15 In October 2010, the Commission applied for permission from the Department to recruit to these business critical posts. The Department agreed that the Commission could seek to fill these vacancies from within the arm s-length bodies, NHS and government redeployment pool and from Audit Commission staff. The Commission did not, however, advertise posts until March In the intervening period, it sought to fill the roles internally from staff being made redundant from a restructuring of its headquarters Insufficient good quality applications were forthcoming from the redeployment pool, and in June 2011 the Commission sought and received approval from the Department to recruit staff on the open market. The Department agreed that the Commission could advertise externally to recruit 106 registration assessors and compliance inspectors. By November 2011, 102 new staff had been recruited.

26 24 Part Two The Care Quality Commission: Regulating the quality and safety of health and adult social care Staff redundancies 2.17 At the same time as vacancies were increasing, the Commission made staff redundant. In , it implemented a voluntary redundancy programme to reduce staff numbers and made 110 staff redundant at a cost of 6.8 million (including 55 inspectors whose redundancy had been agreed by the Commission for Social Care Inspection). In , after a restructuring exercise, a further 140 staff were made redundant, at a cost of 9.2 million. Around 50 redundancies resulted from the Commission s decision to scrap the role of local area manager. These staff were given the opportunity to take up compliance inspector roles or apply for compliance manager posts. Staff morale 2.18 As well as carrying significant numbers of vacancies, the Commission has faced challenges in staff morale. It inherited three sets of pay and conditions from its predecessor bodies, covering some 1,200 staff, and some 600 staff recruited directly by the Commission have a fourth set. Morale has been negatively affected by inconsistencies in pay and conditions, with staff doing the same job on different pay scales. In October 2010, with the Department s support, the Commission contacted the Treasury about its plans to align its pay scales. This would have involved some pay increases. After taking account of the Treasury s views, however, the Department told the Commission that it would not make further representations to the Treasury for an exemption to the pay restraints that are currently in place across the public sector.

27 The Care Quality Commission: Regulating the quality and safety of health and adult social care Part Three 25 Part Three Registering health and adult social care providers 3.1 This part of the report covers the Commission s registration of health and adult social care providers. The registration process 3.2 Under the Health and Social Care Act 2008, providers must register for the types of service they provide. Most registrations are based on a review of documentation, but some involve visiting the provider if the registration assessor judges it necessary. Registration means that the Commission is satisfied that a provider is complying with the essential standards of quality and safety. Providers may be registered with conditions and have to provide the Commission with a plan of how they will meet the conditions. 3.3 Registration was a new requirement for the NHS. Providers of adult social care and independent healthcare were previously registered under the Care Standards Act 2000 but had to re-register under the new legislation. Providers previous registrations could not be transferred because the basis of registration is different (now by service provided rather than establishment). Also, the new essential standards focus more on outcomes (such as users receiving medicines they are prescribed, at the times they need them and in a safe way) rather than processes (such as having appropriate management structures and clear accountability). Progress in registering providers 3.4 The timetable for registering providers did not allow time for the registration process to be tested properly. The process did not run smoothly and, although over 23,000 organisations were registered in total (Figure 11 overleaf), the timetable for two out of three tranches of providers was not met. While existing providers could continue operating while awaiting registration, the public had no independent assurance that the providers concerned were complying with the new essential standards.

28 26 Part Three The Care Quality Commission: Regulating the quality and safety of health and adult social care Figure 11 Number of health and adult social care registrations, to Number of providers (000) , ,435 7,278 6, ,240 1, April to September 2011 NOTE Provider registrations undertaken under the Care Standards Act 2000 Provider registrations undertaken under the Health and Social Care Act The Commission continued to register adult social care providers under the Care Standards Act 2000 prior to the Health and Social Care Act 2008 coming into force. Source: National Audit Office analysis of Commission data 3.5 The registration timetable was set by the Department and given statutory authority in March To help the Commission handle the workload, the timetable was staggered with providers split into tranches according to type. A delay of two months in the Department finalising the registration regulations and their approval by Parliament created uncertainty about some of the details of registration for the Commission and providers. In November 2009, the Commission highlighted to the Department that the delay could potentially undermine effective delivery as it would not have time to test the system properly. The Department s view was that there was adequate time to carry out the necessary testing. 3.6 The Commission met the deadline to register the first tranche of 380 NHS trusts by April 2010 (Figure 12). It did not, however, complete the registration of the second and third tranches covering adult social care providers and independent healthcare providers, and dentists and independent ambulances by the set deadlines. Overall 47 per cent of providers were not registered on time.